Government moves on in-patient care and dual diagnosis win praise

The guidance looks good, say mental health charities, but making
it work in practice will be a truer test of the government’s
resolve. Katie Leason reports.

Mental health service users have three good reasons to be
smiling this week. A high court test case ruling means that
thousands may be able to claim compensation for delayed tribunals
while the Department of Health has recently published guidance
aimed at improving treatment for dual diagnosis
patients¹ and adults in acute
in-patient care.²

The new guidance on dual diagnosis summarises good practice in
mental health services for people with severe mental health
problems who also suffer from substance misuse problems, and is
aimed at those who commission and provide mental health and
substance misuse services.

It states that care for individuals with a dual diagnosis should
be delivered within mental health services. According to the
guidance, substance misuse and mental health services have evolved
separately, meaning that few services currently exist that deal
with clients with both substance misuse and mental health
problems.

Consequently, clients have tended to be either shuttled between
services or treated within one service alone, with some aspects of
their problem not being dealt with sufficiently.

The guidance states that mainstream mental health services have
a responsibility to address the needs of people with a dual
diagnosis, that specialist teams of dual diagnosis workers should
provide support to mainstream mental health services, and that all
staff in assertive outreach teams must be trained and equipped to
work with dual diagnosis.

Drugs charity DrugScope warmly welcomes the guidance, which it
believes will help to improve services for people who have for too
long fallen through the cracks between drug and mental health
services. However the charity warns that a significant investment
is required for training in order for change to be achieved.

DrugScope chief executive Roger Howard says: “It is imperative
that mental health professionals are skilled in dealing with drug
misuse and those working in drug services have knowledge of mental
health illnesses.”

DrugScope also urges the prison service to ensure that it
addresses the needs of people with a dual diagnosis in prison who
“often get caught in the revolving door of the criminal justice
system”.

However, not all individuals with mental health issues and
substance misuse problems have their needs best met by mental
health services.

“If somebody is a recreational drug user who has some mental
health issues then I don’t think that those people are best served
by mental health services,” says Richard McKendrick, operation
manager at charity Turning Point.

He believes that the ideal is integrated care, without a
substance misuse or mental health label.

“It’s about teams being enabled and equipped to deal with people
who turn up at the doorstep,” he says. “The next stage is how we
translate the guidance into action at a national level and that’s
about bringing mental health and substance misuse commissioning
together.”

A second piece of guidance from the DoH is intended to improve
in-patient services for acutely mentally ill adults. Health
minister Jacqui Smith says the intention is “to help raise the
profile of in-patient services and boost the esteem and morale of
those working in them”. The guidance recommends that in-patient
services maximise their connections with community services, that
the key competencies of mental health staff are more closely
defined and incorporated into grading criteria and training
packages, and that the environment and domestic arrangements must
be organised to deliver a comfortable relaxed safe and secure
environment.

Mental health charity Maca welcomes the guidance as a start in
the battle to overcome widespread problems with services. But the
charity does have concerns about how effective the guidance will
be.

“First, the guidance needs to be backed by real new resources to
allow for extra clinical and other support,” says Maca’s head of
public affairs Simon Lawton-Smith. “Second, it needs staff to
listen to what service users, their families and friends are saying
and to make them partners in care. This could be the hardest task
of all to achieve.”

Others are of the opinion that the guidance does not go far
enough. “There isn’t an action plan [in it] that is going to turn
in-patient care around,” says Andrew McCulloch, director of policy
at the Sainsbury Centre for Mental Health. He describes in-patient
care as “pretty awful” and says that without a well-resourced work
programme it will not be turned around.

McCulloch would like to see every patient involved in a
therapeutic programme of daily activity that could include leisure
activities, employment-related activities, occupational therapy and
social activity. “At the moment acute care functions as a place
people are put for a period of time and is not therapeutic,” he
says. He also feels that investment in the estate buildings is
necessary, as poor buildings demoralise staff as well as
patients.

For in-patients who are sectioned and awaiting review, the high
court also offered some promising news when it ruled that the
government had breached the human rights of seven people detained
in psychiatric hospitals by failing to give them speedy reviews of
their detention (News, page 12, 2 May). The patients, who cannot be
named for legal reasons, complained of long delays – in one case 27
weeks – and frequent and repeated cancellations of their
hearings.

The judge said that they had a right to speedy hearings in case
they were wrongly detained, as protected by article 5(4) of the
European Convention on Human Rights. He identified the shortage of
tribunal members, particularly medical members, and lack of staff
training as principal causes for the cancellations and delays and
said the state had not established that it had taken “appropriate
action” to ensure tribunals were adequately staffed.

Simon Foster, principal solicitor at mental health charity Mind,
says there is a shortage of 500 consultant psychiatrists. Moreover,
some psychiatrists are reluctant to sit on tribunals because of
patient commitments and also because the rate of pay available
through tribunals is still below that which they can earn from
other activities.

Lawyers for the seven test case patients said that the ruling
“potentially affects thousands of people throughout England and
Wales”. Last year around 27,000 patients were detained under the
Mental Health Act 1983. Of around 11,500 hearings that took place,
more than 1,000 cases were adjourned. Those patients whose
tribunals were delayed may now be able to claim for
compensation.

“If the hearing was delayed for an unreasonable length of time
then they can claim for the loss of opportunity to have their
detention reviewed,” Foster says. “If they can show they would have
been discharged if the earlier hearing had gone ahead then in some
cases they may be able to claim for false imprisonment.”

However, many individuals may be put off claiming for
compensation because of the cost involved. Legal aid is only
available if the application is cost-effective so short delays of a
couple of days may not be worth pursuing.

A spokesperson for the DoH says the situation regarding delays
and postponements is better now than a year ago and that
difficulties occurred because of a mismatch between the number of
members available to sit on panels and the rising numbers of
applications.

The spokesperson adds that steps are being taken to address the
problem, including proactive recruitment of new members through
campaigns, changes in the retirement rules, a substantial increase
in fees, and the introduction of separate fees for medical
examinations.

It’s not every month that the mental health field enjoys such
attention but perhaps it would be safer to balance any optimism
with a degree of caution before the dawn of a new era is declared.
After all, little progress still appears to have been made on the
reform of the Mental Health Act, with the government claiming that
new mental health legislation will be introduced “as soon as
parliamentary time allows”.

The new guidance is welcome – but to improve services it must be
accompanied with additional resources or risk remaining little more
than guidance.

¹ Department of Health, Dual
Diagnosis Provision, DoH, April 2002

² Department of Health, Mental
Health Policy Implementation Guide: Adult Acute Inpatient Care
Provision, DoH, March 2002

Both documents can be found at www.doh.gov.uk/mentalhealth/index.htm